What is the treatment for allergic rhinitis?

Treatment of Allergic Rhinitis

Intranasal corticosteroids are the most effective medication class for controlling allergic rhinitis symptoms and should be considered first-line therapy for moderate to severe cases. 1

Diagnosis and Clinical Presentation

Allergic rhinitis typically presents with:

• Nasal congestion
• Rhinorrhea (runny nose)
• Sneezing
• Itching of the nose, eyes, and throat 2

Physical examination may reveal:

• Edematous and pale turbinates (seasonal allergic rhinitis)
• Erythematous and inflamed turbinates with serous secretions (perennial allergic rhinitis) 2

Treatment Algorithm

First-Line Treatment Options:

1. For Mild Intermittent or Mild Persistent Allergic Rhinitis:

   • Second-generation oral antihistamines (cetirizine, fexofenadine, desloratadine, loratadine) 2
   • OR intranasal antihistamines (azelastine, olopatadine) 1

2. For Moderate to Severe Persistent Allergic Rhinitis:

   • Intranasal corticosteroids (fluticasone, triamcinolone, budesonide, mometasone) 1, 2
   • OR combination of intranasal corticosteroid plus intranasal antihistamine 1

Environmental Control Measures:

• Identify and avoid allergen triggers (pollens, fungi, dust mites, animal dander) 1
• For pollen allergies: limit outdoor exposure during high pollen counts 1
• For dust mite allergies: use dust mite covers for bedding, HEPA vacuuming, humidity control 1
• For animal allergies: avoidance is most effective 1
• For indoor fungi: remove moisture sources and use dilute bleach on non-porous surfaces 1

Medication Details

Intranasal Corticosteroids:

• Most effective for controlling all symptoms including nasal congestion 1
• Work by acting on multiple inflammatory substances (histamine, prostaglandins, cytokines, tryptases, chemokines, leukotrienes) 3
• May take several days to reach maximum effect; best used regularly once daily 3
• Minimal systemic side effects at recommended doses 1
• Local side effects may include nasal irritation and bleeding 1

Second-Generation Antihistamines:

• Preferred over first-generation antihistamines due to less sedation and fewer anticholinergic effects 1, 4
• Effective for rhinorrhea, sneezing, and itching but less effective for nasal congestion 2
• Differences in sedative properties:
  • Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses
  • Loratadine and desloratadine may cause sedation at higher doses
  • Cetirizine may cause sedation at recommended doses 1

Intranasal Antihistamines:

• May be used as first-line treatment for allergic and nonallergic rhinitis 1
• Equal to or superior to oral second-generation antihistamines for seasonal allergic rhinitis 1
• Can have a clinically significant effect on nasal congestion 1
• Generally less effective than intranasal corticosteroids 1

Combination Therapy:

• For moderate to severe symptoms, combination of intranasal corticosteroid and intranasal antihistamine may be more effective than either agent alone 1

Other Treatment Options:

• Leukotriene receptor antagonists (montelukast) can be useful but are less effective than intranasal corticosteroids 1
• Intranasal cromolyn sodium is effective for some patients but less effective than corticosteroids 1
• Nasal saline is beneficial for chronic rhinorrhea and rhinosinusitis 1
• Oral decongestants (pseudoephedrine, phenylephrine) can reduce nasal congestion but may cause side effects like insomnia, irritability, and palpitations 1
• Intranasal anticholinergics (ipratropium) may effectively reduce rhinorrhea but have no effect on other symptoms 1

Special Considerations

Pitfalls to Avoid:

• Using first-generation antihistamines which cause significant sedation, performance impairment, and anticholinergic effects 1, 4
• Using topical decongestants for more than 3 days (risk of rhinitis medicamentosa) 1
• Single or recurrent administration of parenteral corticosteroids (contraindicated due to potential long-term side effects) 1
• Failing to consider comorbid conditions like asthma, sinusitis, and sleep apnea 1

For Children (Ages 4-11):

• Lower dose of intranasal corticosteroids
• Limited to 2 months of use per year before consulting a doctor (concerns about potential growth effects) 3

For Severe or Intractable Symptoms:

• A short course (5-7 days) of oral corticosteroids may be appropriate 1
• Allergen immunotherapy should be considered for patients with specific IgE antibodies to clinically relevant allergens who have inadequate response to medications 1

Monitoring and Follow-up

• Assess response to treatment and adjust as needed
• Monitor for medication side effects
• For patients using intranasal corticosteroids, periodically examine the nasal septum 1
• For children using intranasal corticosteroids, monitor growth 3